HEALTH PROVISIONS · 6 MIN READ

No Surprises Act and Mental Health Parity

The federal No Surprises Act protects patients from balance billing in three settings: out-of-network emergency services, non-emergency services delivered by out-of-network providers at in-network facilities, and air ambulance transports. The patient pays only in-network cost-sharing; the payment fight moves to the plan and provider. The dispute machinery runs on a strict clock: the plan must make an initial payment or send a denial notice within 30 calendar days of receiving a clean claim; the parties then have a 30-business-day open negotiation period; and if that fails, either side has 4 business days to initiate the federal Independent Dispute Resolution (IDR) process before a certified arbitration entity. A narrow notice-and-consent exception lets some out-of-network providers at in-network facilities bill out-of-network rates — but only for non-emergency, non-ancillary scheduled services, with written notice at least 72 hours in advance and the patient's signature on a standardized consent. Categorically non-waivable: emergency services, ancillary services (anesthesiology, pathology, radiology, neonatology, assistant surgeons, hospitalists, intensivists), services where no in-network provider is available, related diagnostic services, unforeseen urgent needs — and air ambulance, which can never use notice-and-consent. Uninsured and self-pay patients get their own protection: a written Good Faith Estimate of expected charges, due within 1 business day of scheduling when the service is 3-9 business days away and within 3 business days when it is 10 or more days out. The Mental Health Parity and Addiction Equity Act (MHPAEA) attacks a different inequity: plans covering mental health or substance use disorder benefits must treat them no more restrictively than medical/surgical benefits. Parity is tested across six classifications of benefits, and financial requirements or quantitative treatment limits applied to mental health benefits must pass the substantially-all / predominant test measured against the medical/surgical side of each classification. Nonquantitative treatment limitations — like preauthorization requirements, step therapy, and network admission standards — must also be applied comparably. Related federal rules round out this landscape, including anti-discrimination protections and pandemic-era telehealth expansions.